415600976-6-11-2021-14-AS-JVAO-C3VTN5-20210611145210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 06/11/2021
Date Signed: 06/11/2021 02:52:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	PENINSULA REFLECTIONS		FACILITY NUMBER:	415600976
ADMINISTRATOR:	ANNA ALLAS		FACILITY TYPE:	740
ADDRESS:	205 COLLINS AVE		TELEPHONE:	(650) 731-4670
CITY:	COLMA	STATE: CA	ZIP CODE:	94014
CAPACITY:	57	CENSUS: 39	DATE:	06/11/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kathy Nguyen		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On June 11, 2021 Licensing Program Analyst (LPA) Jaime Vado met with Wellness Director Kathy Nguyen for a Case Management visit to follow up on a complaint regarding physical abuse on a resident. On February 12, 2019, LPA Marie Rodriguez conducted an unannounced Case Management visit in response to information received by the Department through online news articles. On February 11, 2019, the Department was made aware of a news article dated February 6, 2019, written by a local media source. This news article was an update to a previous report from October 25, 2018. It was reported that facility medical technician, Staff 1 (S1), was charged with attempted voluntary manslaughter and elder abuse. The facility medical technician, S1, had pushed a pillow down on a resident’s (R1) face diagnosed with dementia. S1 was arrested and transported to a local County jail on October 23, 2018, pending further investigation. The investigation consisted of administrator and witness interviews and the collection of physical and audio evidence such as the pillows used by S1 and an audio recording of the incident. Officers conducted interviews with Peninsula Reflections Administrator and S2, an employee who was present at the time S1 pushed a pillow down on R1’s face. Administrator’s interview pointed to S2 as the only witness to the event. The interview with S2 revealed another incident that occurred the previous week of October 23, 2018. For the incident of the previous week, S2 described a different resident as potentially combative and difficult, but also added that these were the patients they dealt with because the facility is a dementia facility. S2 said S1 yelled at this resident, saying, “shut your f--king mouth,” while S1 took the resident to the resident’s room. Regarding R1’s incident, R1 was reported to have been blocking R1’s room door with R1’s walker. S2 noted that R1 had never blocked R1’s door before S1 began working at the facility. It seems R1 had felt safer with the walker in front of R1’s door as S2 described the habit. S2 continued detailing how S2 had witnessed S1 get upset with R1 and forced S1 to R1’s room. S1 grabbed R1’s arm along the way then tossed R1 on to R1’s bed. S1 took R1’s shoes off, throwing them on the ground, and then grabbed a pillow and forcefully put it over R1’s face. S2 recorded the incident on video and then intervened to stop S1. The video clip from the evening of October 18, 2018 and October 19, 2018 revealed an exchange of words, a minute long, in Tagalog and Illocano (Filipino dialect). The recording unveils S1’s violent actions and R1’s reactions. S2 noted that S1 acts one way with management staff and another way with the patients and residents. S2 also added that the reason she recorded the incident was because when S2 had reported a prior incident regarding S1, management did not believe S2. Continued on next page...

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
	VISIT DATE: 06/11/2021

NARRATIVE

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Page 2 - LIC809

Additionally, S2 believes that if S2 did not grab S1 and get S1 off R1, S1 would have suffocated R1 to death. Approximately 10-15 minutes later, S1 told S2, “I don’t think this job is for me.” S2 also notes that while S2 has been a caretaker for R1, S2 has never seen R1 frightened or defensive when another caretaker was nearby, except for S1. S2 believes R1 is afraid of S1.

The allegations regarding R1 were confirmed by S1 himself. S1 stated that S1 and R1, who is diagnosed with dementia, had numerous verbal disagreements in the past, and R1 would call S1 bad names and get angry with S1 frequently. S1 told officers S1 was just angry and wanted R1 to go to bed and not argue with S1. S1 stated S1 had pushed the pillow down on the resident’s face for approximately five seconds before stopping. S1 revealed what R1 had said during the incident, “Are you going to kill me?” And S1 replied with, “Yes, I am going to kill you if you don’t go to bed.” After officers confirmed this was fact, S1 told officers that S1 could have killed R1 and that “circumstances forced me to do it because I was stressed out.” S1 added that S1 was just trying to make R1 shut up and go back to bed.

Based on all the evidence collected, the police report and interviews, S1 attacked and attempted to suffocated R1, who is diagnosed with dementia, with a pillow to silence R1. Additional evidence points to a previous outburst of anger and violence from S1 towards another resident. With a profession as a facility medical technician, S1 has exhibited violence and anger that place the residents S1 is assigned to take care of, with varying illnesses, and potential coworkers, in danger. S1 attempted to suffocate R1 with a pillow that could have resulted in R1’s death and meets the definition of physical abuse.

At the time of the complaint visit on February 12, 2019, the issuance of a civil penalty was still being determined based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. Per Welfare and Institutions Code § 15610.63 defines physical abuse as, “(a) Assault, as defined in Section 240 of the Penal Code.” PC Section 240: “An assault is an unlawful attempt, coupled with a present ability, to commit a violent injury on the person of another.”

Today, June 11, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as physical abuse in the amount of $10,000.

A copy of the LIC 421D was given to Kathy Nguyen and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Kathy Nguyen's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/12/2021 Section Cited	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities - To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: As a result of the investigation sufficient evidence showed that S1 knowingly pushed the pillow down against the face of R1 even though he was aware that his actions could directly jeapoardize the life, and health and safety, of R1. A civil penalty of $10,000 is being assessed against the facility per Health and Safety Code § 1569.49 for a violation that the Department constitutes as physical abuse	8 9 10 11 12 13 14	POC to be received in CCL by due date.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3